NSG 430 Exam 13 (Complete And Verified Study material) (130pages) LEARNEXAMS

1. The nurse is caring for an unresponsive terminally ill patient who has20-second periods of apnea followed by periods of deep and rapid breathing.Which action wouldthe nurse take? A. Suction the patient's mouth. B. Administer oxygen via face mask. C. Document the patient's respiratory pattern. D. Place the patient in high Fowler's position.: Answer Document the patient'srespiratorypattern Cheyne-Stokes respirations are characterized by periods of apnea alternating withdeep and rapid breaths.This respiratory pattern is expected in the last days of life and is notposition dependent.There is also no need forsupplemental oxygen by face mask orsuction-ing the patient. 2. The nurse is caring for a dying adolescent patient who is comatose.Thepatient's parents are interested in organ donation and ask the nurse how the health care providersdetermine brain death.Which response by the nurse accurately describes brain death determination? A. If CPR does not restore a heartbeat, the brain cannot function any longer. B. Brain death has occurred if there is not any breathing or brainstem reflexes. C. Brain death has occurred if a person has flaccid muscles and does notawaken. D. If respiratory efforts cease and no apical pulse is audible, brain death is present.: Answer Brain death has occurred if there is not any breathing or brainstemreflexes. The diagnosis of brain death is based on irreversible loss of all brain functions,including brainstem functions that control respirations and brainstem reflexes.The otherdescriptions describe other clinical manifestations associated with death but are insufficient todeclare a patient brain dead. 3. A patient in hospice is manifesting a decrease in all body system functionsexcept for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min.Which statementwould be accurate for the nurse to make to the patient's family? A. These vital signs will continue to increase until death finally occurs. B. These vital signs demonstrate the body's ability to compensate and heal. C. These vital signs are an expected response now but will slow down later.